Implementation of NICE clinical guideline 95 on chest pain of recent onset: experience in a district general hospital.

The National Institute for Health and Care Excellence (NICE) CG95 clinical guideline on chest pain of recent onset was published in 2010. There is debate over whether the proposed strategy improves patient care and its implications on service costs. Following a six-month pilot, 472 consecutive patient records were audited for pre-test probability of significant coronary artery disease, investigations performed and outcomes. Low- and moderate-risk patients had an unexpectedly low rate of coronary disease and revascularisation. Computerised tomography coronary angiography (CTCA) and stress echocardiography performed similarly, though the latter was more resource intensive. High-/very high-risk patients frequently required revascularisation and greater than 10% of each group had prognostically significant disease, going against the recommendation that very high risk patients do not undergo angiography. There were frequent protocol deviations and training clinic staff in the new approach was challenging. In conclusion, implementing NICE CG95 is feasible but presents challenges. Staff require training to follow the protocol consistently. Functional testing had no benefits over anatomical testing with CTCA, which may allow cost savings in some departments.

Hypereosinophilic syndrome masquerading as a myocardial infarction causing decompensated heart failure.

BACKGROUND: An 81 year old female patient diagnosed with a chronic low grade hypereosinophilic syndrome presented with angina and dyspnoea. CASE PRESENTATION: She was managed for a non-ST elevated myocardial infarction since her troponin levels were elevated. On day 5, she suffered an acute clinical deterioration with type I respiratory failure and cardiogenic shock, accompanied by deterioration in left ventricular systolic function demonstrated on echocardiography, and this coincided with a marked rise in eosinophil count. Secondary causes of eosinophilia were excluded permitting a diagnosis of Hypereosinophilic Syndrome (HES) to be made. Coronary angiography revealed unobstructed arteries. Supportive treatment for heart failure included diuretic and inotropes but she dramatically improved both clinically and echocardiographically upon commencement of high dose steroids and hydroxycarbamide. Cardiac magnetic resonance imaging (CMR) demonstrated diffuse, shallow endomyocardial enhancement with late gadolinium, consistent with a diagnosis of eosinophilic myocarditis. CONCLUSION: Hypereosinophilic Syndrome can masquerade as a myocardial infarction causing decompensated heart failure. Early recognition and treatment with steroids can improve outcome.

Giant proximal left anterior descending aneurysm causing multi-vessel myocardial ischaemia: the pressure is on-a case report.

Background: Giant coronary artery aneurysms are a rare cause of myocardial ischaemia. Due to the rarity and variety of presentation of these cases, no standardized investigation or treatment has been established for management. We report a case study of a giant proximal left anterior descending (LAD) coronary aneurysm causing myocardial ischaemia due to the pressure effect from the weight of the aneurysm as well as from a change in rheology from a 'steal effect' on both the LAD and left circumflex (LCx) arteries. Case summary: A 55-year-old patient presents initially with a history of angina. Initial investigation with computed tomography (CT) was suboptimal, requiring invasive diagnostic angiography, which detects a giant proximal LAD aneurysm. Subsequent investigations, with CT-fractional flow reserve (FFR) and stress echocardiography (ECHO), correlated to identify multi-vessel ischaemia resulting from the aneurysm. The patient was managed with multi-disciplinary team-led surgical resection and triple coronary artery bypass grafts with good results. Discussion: This case highlights the complexity of coronary anomalies and importance of additional functional three-dimensional imaging on top of the static computational tomography coronary angiography analysis. Together, these two complimentary investigations qualitatively enabled the assessment of anomaly with surrounding structures such that the possibility of a mass effect on the LCx artery results in a positive stress test. Furthermore, this is a novel use of CT-FFR for coronary anomalies and it demonstrated good correlation of LAD territory ischaemia between CT-FFR and the stress ECHO.

Randomized comparison of the magnetic navigation system vs. standard wires in the treatment of bifurcations.

Aims Randomly compare the magnetic navigation system (MNS) to standard guidewire techniques in managing bifurcating lesions. Methods and results Thirty-one consecutive patients with bifurcating lesions were randomized to cross the bifurcating vessels prior to treatment and thereafter the struts of deployed stents with either magnetic or standard guidewires. Crossing success, crossing/fluoroscopy times, and contrast media usage were directly compared. Similar times were noted in both the magnetic wire crossings (median, IQR; 68 s, 45-138 s vs. 59 s, 32-133 s) and fluoroscopic times (median, IQR; 62 s, 44-135 s vs. 55 s, 27-133 s) when compared with standard conventional wires passage through the deployed struts. The MNS successful crossings were 30/31 (96.8%) compared with 28/31 (90.0%) observed with the standard wires. Two previously failed standard wire cases were successfully crossed with magnetic guidewires. Conclusion In contemporary stented bifurcations, the MNS achieved equivalent crossing/fluoroscopy times through deployed stents struts and may be useful in salvaging failed standard wire cases.

Non-invasive diagnostic workup of patients with suspected stable angina by combined computed tomography coronary angiography and magnetic resonance perfusion imaging.

BACKGROUND: To evaluate additional adenosine magnetic resonance perfusion (MRP) imaging in the diagnostic workup of patients with suspected stable angina with computed tomography coronary angiography (CTCA) as first-line diagnostic modality. METHODS AND RESULTS: Two hundred and thirty symptomatic patients (male, 52%; age, 56 year) with suspected stable angina underwent CTCA. In patients with a stenosis of >50% as visually assessed, MRP was performed and the quantitative myocardial perfusion reserve index (MPRI) was calculated. Coronary flow reserve (CFR) using invasive coronary flow measurements served as the standard of reference. CTCA showed non-significant CAD in 151/230 (66%) patients and significant CAD in 79/230 patients (34%), of whom 50 subsequently underwent MRP and CFR. MRP showed reduced perfusion in 32 patients (64%), which was confirmed by CFR in 27 (84%). All 18 cases of normal MRP (36%) were confirmed by CFR. The positive likelihood ratio of MRP for the presence of functional significant disease in patients with a lesion on CTCA was 4.49 (95% confidence interval [CI] 2.12-9.99). The negative likelihood ratio was 0.05 (95%CI 0.01-0.34). CONCLUSIONS: CTCA as first-line diagnostic modality excluded coronary artery disease in a high percentage of patients referred for diagnostic workup of suspected stable angina. MRP made a significant contribution to the detection of functional significant lesions in patients with a positive CTCA.

The Tryton® dedicated bifurcation stent: Five-year clinical outcomes.

AIMS: We report the first 5 year clinical follow-up data for the Tryton® bifurcation stent. METHODS AND RESULTS: Clinical outcomes at five years were collected from 8 centres. Non-hierarchical Major Adverse Cardiovascular Events (MACE) and Major Adverse Cerebrovascular and Cardiovascular Events (MACCE) were collected. Diabetic and non-diabetic populations were compared, along with small (≤2.5 mm) vs large (>2.5 mm) side branch size. 173 patients with a follow up rate of 98% at 5 years were analysed. Non-hierarchical MACE was low at 9.8%, consisting of cardiac death of 1.2% (n = 2) and MI of 1.7% (n = 3). Target lesion revascularization (TLR) rate was 6.9% (n = 12). Non-hierarchical MACCE was also low, with major bleeding in 2.3% (n = 4) and strokes in 1.7% (n = 3) of patients. There was only 1 case (0.6%) of stent thrombosis that was definite and occurred very late (782 days). All-cause mortality was low, with 8.7% combined cardiac and non-cardiac death (n = 15). Diabetic patients had significantly higher event rates, but there was no difference in events with lesion stratification by side branch size. CONCLUSIONS: The Tryton® Side-Branch Stent has a non-hierarchical MACE of 9.8% and MACCE of 13.9% at 5 years. The TLR was 6.9% with only 1 case of stent thrombosis recorded.

A randomized comparison of the magnetic navigation system versus conventional percutaneous coronary intervention.

OBJECTIVE: A randomized comparison of the magnetic navigation system (MNS) to conventional guidewire techniques in percutaneous coronary interventions. BACKGROUND: The MNS precisely directs a magnetized guidewire in vivo through two permanent external magnets. METHODS: A total of 111 consecutive patients were enrolled. Crossing success, crossing-/fluoroscopy times, and contrast usage were directly compared. Lesions were classified according to the AHA/ACC criteria. Three tertiles of vessel/lesion complexity [low (<5), medium (6-10) and high (>10)] were defined using 3D reconstructions and angiographic information. RESULTS: The crossing success for magnetic and the conventional wires were 93.3 and 95.6%, respectively. Crossing and fluoroscopy times were longer with the magnetic wires (72.9 +/- 50.3 sec vs. 58.1 +/- 47.2 sec, P < 0.001 and 66.2 +/- 44.1 sec vs. 55.2 +/- 44.4 sec, P = 0.03, respectively). In vessels with low and medium complexity the magnetic wires had significantly longer times (P < 0.001) but for those with high scores (>10) a trend towards shorter times was observed. The MNS resulted in a small but significant reduction in contrast usage (2.3 +/- 3.5 ml vs. 4.5 +/- 4.4 ml, P < 0.001). Moreover by superimposing a virtual roadmap of the vessel on the live fluoroscopy image 48% of the lesions were crossed without requiring contrast agents with the MNS. CONCLUSION: The MNS has comparable crossing success to conventional PCI. It is relatively slower but there is a trend to support a potential advantage in more complex vessels. By simultaneously employing a virtual roadmap there is a small but significant reduction in contrast usage.

First direct in vivo comparison of two commercially available three-dimensional quantitative coronary angiography systems.

AIM: The in vivo comparison of the accuracy of two 3-dimensional quantitative coronary angiography (QCA) systems. METHODS: Precision-drilled plexiglass phantoms with five different luminal diameters (0.5-1.9 mm) were percutaneously inserted into the coronary arteries of four Yorkshire pigs. Twenty-one angiographic images of these stenotic phantoms were acquired for in vivo validation testing. Quantitative assessments of the minimum, maximum, and mean luminal diameters together with the minimum luminal area were determined using two 3D QCA systems, the CardiOp-B and CAAS 5. RESULTS: The CardiOp-B system significantly underestimated the minimum luminal diameter MLD whilst both systems significantly overestimated the maximum luminal diameter at the minimal luminal area (MLA) over the phantom's true value. The CAAS 5 system had a greater degree of accuracy/mm (mean difference = 0.01 vs. 0.03) and precision/mm (SD = 0.09 vs. 0.23) than the CardiOp-B in assessing the minimal LD. An increased precision/mm (SD = 0.01 vs. 0.29) and accuracy/mm (mean difference = 0.03 vs. 0.11) in the mean LD was observed with the CAAS 5. In comparing the MLA/mm(2) the CAAS 5 was more precise/mm(2) (SD = 0.14 vs. 0.55) and accurate/mm(2) (mean difference = 0.12 vs. 0.02) to the true phantom MLA compared to the CardiOp-B system. CONCLUSIONS: In a 21 phantom study, the CAAS 5 3D QCA system had a greater degree of accuracy and precision in both the luminal and area measurements than the CardiOp-B 3D QCA system.

Fully biodegradable coronary stents : progress to date.

The limitations of currently available metallic drug-eluting stents have renewed interest in biodegradable stents (BDS). Apart from removing the (offending) foreign material that may potentiate a thrombotic event, BDS have the advantage of avoiding 'full metal jackets,' and thus can preclude subsequent coronary surgery. In addition, they do not interfere with the diagnostic evaluation of non-invasive imaging such as cardiac magnetic resonance and CT. There are now several BDS in development or in clinical trials that incorporate a variety of biodegradable polymer technologies. Two broad categories of materials are generally used: those made from organic biopolymers and those made from corrodible metals. However, to date, none of the materials/stents tested have been able to establish a perfect balance between biocompatibility, the kinetics of degradation needed to maintain mechanical strength to limit recoil, and inflammation. However, studies, such as the ABSORB trial with the everolimus eluting poly-L-lactide stent, which demonstrated comparable restenotic rates with bare metallic stents and a low incidence of major adverse cardiac events (MACE) at 12 months of 3.3%, with only one patient having a non-Q-wave myocardial infarction and no target lesion revascularization, suggest that there has been significant progress with respect to the earlier prototypes. The acute recoil observed could potentially be addressed with the polytyrosine REVA stent currently being evaluated in the RESORB trial, which incorporates a novel locking mechanism within its design. Alternative BDS designs include the combination of an antiproliferative drug with endothelial progenitor cell capturing antibodies to facilitate epithelialization and/or dual eluting having, in addition to the antiproliferative drug, polymeric salicyclic acid to limit inflammation. Compared with biodegradable polymers, there are fewer metals used in the manufacture of BDS. The only metal BDS in trials is the Biotronik absorbable magnesium stent, which showed a MACE of 26.7% at 12 months without deaths, stent thrombosis, or acute myocardial infarction in the PROGRESS-AMS trial. Unlike magnesium stents, there has been little progress with iron stents, which remain in the pre-clinical phase, and this may be partly due to the longer degradation times needed and potential issues related with iron clearance.

Magnetically guided left ventricular lead implantation based on a virtual three-dimensional reconstructed image of the coronary sinus.

AIMS: Left ventricular (LV) lead implantation is feasible using remote magnetic navigation of a guidewire (Stereotaxis, St Louis, MO, USA). A novel software that performs a three-dimensional (3D) reconstruction of vessels based on two or more angiographic views has been developed recently (CardiOp-B system, Paeion Inc., Haifa, Israel). The objective of this paper is to evaluate: (i) the performance of the 3D reconstruction software which reproduce the anatomy of the coronary sinus (CS) and (ii) the efficacy of remotely navigating a magnetic guidewire within the CS based on this reconstruction. METHODS AND RESULTS: In patients undergoing cardiac resynchronization therapy implantation, a 3D reconstruction of the CS was performed using the CardiOp-B system. Accuracy of the reconstruction was evaluated by comparing with the CS angiogram. This reconstruction was imported into the Stereotaxis system. On the basis of the reconstruction, magnetic vectors were automatically selected to navigate within the CS and manually adjusted if required. Feasibility of deploying the guidewire and LV lead into the selected side branch (SB), fluoroscopy time (FT) required for cannulation of the target SB, and total FT were also evaluated. Sixteen patients were included. In one case, the software could not reconstruct the CS. The quality of the reconstruction was graded as good in 13 and poor in 2. In 10 cases, manual adjustments to the traced edges of the CS were required to perform the 3D reconstruction, and in 5, no adjustments were required. In 13 patients, the target SB was engaged on the basis of the automatically selected vectors. In two cases, manual modification of the vector was required. Mean total FT was 23 +/- 14 min and the FT required to cannulate the target SB was 1.7 +/- 1.3 min. CONCLUSION: A 3D reconstruction of the CS can be accurately performed using two angiographic views. This reconstruction allows precise magnetic navigation of a guidewire within the CS.

The next generation of drug-eluting stents: what's on the horizon?

Drug-eluting stents have radically changed the way we treat coronary artery disease. They offer lower restenotic rates compared with the bare metal stents and this enables more challenging and complex lesions to be treated. However, there are still limitations as restenosis has not been completely abolished and there are concerns about stent thrombosis. The next generation stents offer the technology to address these pertinent issues. This review examines the new analogs of the sirolimus family and their use in novel stent platforms, including the use of biodegradable and bioabsorbable materials employed in both stents and on the polymer. "Reservoir stents" that are specially designed to contain layers of drugs in pockets with different release profiles are discussed and an insight into the emerging field of bioengineered stents is highlighted.

Newer stents: looking at the horizon.

More challenging and complex lesions are being treated with drug:eluting stents. This review examines advances in some of the commercially available stents together with important new stents under development. These include stents with novel platforms for drug elution, biodegradable, and bioabsorbable polymer/stents and stents dedicated to specific lesions. It also discusses novel pharmacological agents aimed at targeting inflammation and restenosis together with bio-engineered stents and combination drug therapies.

Left atrial volume index in patients with heart failure and severely impaired left ventricular systolic function: the role of established echocardiographic parameters, circulating cystatin C and galectin-3.

Backround: Left atrial (LA) enlargement plays an important role in the development of heart failure (HF) and is a robust prognostic factor. Fibrotic processes have also been advocated to evoke HF through finite signalling proteins. METHODS: We examined the association of two such proteins, cystatin C (CysC) and galectin-3 (Gal-3), and other clinical, echocardiographic and biochemical parameters with LA volume index (LAVi) in patients with HF with severely impaired left ventricular ejection fraction (LVEF). Severe renal, liver, autoimmune disease and cancer were exclusion criteria. RESULTS: A total of 40 patients with HF (31 men, age 66.6 ± 1.7) with LVEF = 25.4 ± 0.9% were divided into two groups according to the mean LAVi (51.03 ± 2.9 ml/m2) calculated by two-dimensional transthoracic echocardiography. Greater LAVi was positively associated with LV end-diastolic volume ( p = 0.017), LV end-systolic volume ( p = 0.025), mitral regurgitant volume (MRV) ( p = 0.001), right ventricular systolic pressure (RVSP) ( p < 0.001), restrictive diastolic filling pattern ( p = 0.003) and atrial fibrillation ( p = 0.005). Plasma CysC was positively correlated with LAVi ( R2 = 0.135, p = 0.019) and log-transformed plasma Gal-3 ( R2 = 0.109, p = 0.042) by simple linear regression analysis. Stepwise multiple linear regression analysis showed that only MRV ( t = 2.236, p = 0.032), CysC ( t = 2.467, p = 0.019) and RVSP ( t = 2.155, p = 0.038) were significant predictors of LAVi. CONCLUSIONS: Apart from known determinants of LAVi, circulating CysC and Gal-3 were associated with greater LA dilatation in patients with HF with reduced LVEF. Interestingly, the correlation between these two fibrotic proteins was positive.

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR).

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.

Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital.

Clinical documentation is an integral part of the healthcare professional's job. Good record keeping is essential for patient care, accurate recording of consultations and for effective communication within the multidisciplinary team. Within the surgical department at the Great Western Hospital, Swindon, the case notes were deemed to be bulky and cumbersome, inhibiting effective record keeping, potentially putting patients' at risk. The aim of this quality improvement project was therefore to improve the standard of documentation, the labelling of notes and the overall filing. A baseline audit was firstly undertaken assessing the notes within the busiest surgical ward. A number of variables were assessed, but notably, only 12% (4/33) of the case notes were found to be without loose pages. Furthermore, less than half of the pages with entries written within the last 72 hours contained adequate patient identifiers on them. When assessing these entries further, the designation of the writer was only recorded in one third (11/33) of the cases, whilst the printed name of the writer was only recorded in 65% (21/33) of the entries. This project ran over a 10 month period, using a plan, do study, act methodology. Initial focus was on simple education. Afterwards, single admission folders were introduced, to contain only information required for that admission, in an attempt to streamline the notes and ease the filing. This saw a global improvement across all data subsets, with a sustained improvement of over 80% compliance seen. An educational poster was also created and displayed in clinical areas, to remind users to label their notes with patient identifying stickers. This saw a 4-fold increase (16%-68%) in the labelling of notes. In conclusion, simple, cost effective measures in streamlining medical notes, improves the quality of documentation, facilitates the filing and ultimately improves patient care.

The need for dedicated bifurcation quantitative coronary angiography (QCA) software algorithms to evaluate bifurcation lesions.

Single-vessel quantitative coronary angiography (QCA) software is inaccurate when used in bifurcation lesions due to the specific anatomical characteristics of bifurcations, including the natural step-down in diameters after every bifurcation. Dedicated bifurcation QCA software has been developed to overcome the limitations of single-vessel QCA in bifurcations. A phantom validation study has shown the superior accuracy of these bifurcation QCA algorithms compared to the single-vessel QCA software. These QCA software algorithms are currently highly recommended to assess bifurcation lesions.

"SHOUT" to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital.

Acute kidney injury (AKI) affects up to 20% of all patients admitted to hospital, and is associated with a higher risk of adverse clinical outcomes, increased healthcare costs, as well as long term risks of chronic kidney disease and end stage renal failure. The aim of this project was to improve the quality of care for patients with AKI admitted to the acute medical unit (AMU) at the Great Western Hospital (GWH). We assessed awareness and self reported confidence among physicians in our Trust, in addition to basic aspects of care relevant to AKI on our AMU. A multifaceted quality improvement strategy was developed, which included measures to improve awareness such as a Trust wide AKI awareness day, and reconfiguring the admission proforma on our AMU in order to enhance risk assessment, staging, and early response to AKI. Ancillary measures such as the dissemination of flashcards for lanyards containing core information were also used. Follow up assessments showed that foundation year one (FY1) doctors' self reported confidence in managing AKI increased from 2.8 to 4.2, as measured on a five point Likert scale (P=0.0003). AKI risk assessment increased from 13% to 57% (P=0.07) following a change in the admission proforma. Documentation of the diagnosis of AKI increased from 66% to 95% (P=0.038) among flagged patients. Documentation of urine dip results increased from 33% to 73% (P=0.01), in addition to a rise in appropriate referral for specialist input, although this was not statistically significant. Our results suggest that using the twin approaches of improving awareness, and small changes to systemic factors such as modification of the admission proforma, can lead to significant enhancements in the quality of care of patients with AKI.

Virtual histology assessment of coronary atheroma influences treatment strategy in the young acute coronary syndrome patient.

A 43-year-old woman having significant risk factors for ischaemic heart disease was admitted with an acute coronary syndrome (ACS). Coronary angiography revealed a non-flow limiting lesion in her right coronary artery with the rest of her arteries unremarkable. Risk stratification of the culprit lesion in the right coronary artery through intravascular ultrasound virtual histology demonstrated that the rupture plaque had less than 5% necrotic core with low vulnerability indices. This important finding suggested that the re-rupture risk was low so aggressive pharmacological treatment that can influence the plaque characteristics was instigated in preference to mechanical plaque sealing with a coronary stent. At a year of follow-up the patient was well and had no further events.